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This is a case report of a patient who died from acute aortic dissection after awake intubation. An 86-year-old woman with neck abscess causing dyspnea and hypertension was scheduled for a tracheotomy. Awake intubation was chosen and fentanyl 150 μg was injected first Immediately after intubation using a McGRATH® scope, her blood pressure increased to 205/157 mmHg and about 5 minutes after induction following intubation, end-tidal CO₂ suddenly decreased. Aortic dissection was found with transesophageal echocardiography, and soon after, the electrocardio- gram of the patient showed an asystole. The patient was confirmed dead after effort to resuscitate. Chest CT revealed the wide range of aortic dissection from the aortic arch to the abdominal aorta. Hemodynamic change occurs at the time of intuba- tion, and its change is greater in elderly and those with hypertension. Furthermore, an interrelation between apnea and aortic dissection or large diameter of aneu- rysms has been reported. Therefore, anesthesia for elderly, especially those with hypertension, requires greater attention to their hemodynamic changes.